Transcript Gender Differences in Prescribing Drugs Potentially Harmful to Elderly in Managed Care

Gender Differences in
Prescribing Drugs
Potentially Harmful to
Elderly in Managed Care
Lok Wong, MHS; Russell Mardon, PhD; Phil
Renner, MBA - National Committee for
Quality Assurance; Arlene Bierman, MD, MS
- University of Toronto
Academy Health June 2005
Assessing and Improving Quality of Care
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by Gender
Acknowledgements
NCQA Geriatric Measurement Advisory Panel
Medication Management Technical Subgroup
Arlene Bierman, MD, MS ;
Emerald Foster, Pharm.D., CGP;
Jerry Gurwitz, MD;
Joseph T. Hanlon, Pharm.D. ;
Mark E. Lehman, Pharm.D. FASCP;
Edward Westrick, MD, PhD
This study was supported by the Centers for
Medicaid and Medicare Services (CMS) under a
HEDIS contract
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Gender - Research Objective
• Population-based studies found older
women more likely to receive potentially
inappropriate drugs than older men.
• Question: Do gender differences in drug
prescribing patterns exist within Medicare
managed care plans?
• Question: Are elderly women enrollees
more likely than elderly men to receive
drugs potentially harmful to the elderly?
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Consensus on Harmful Drugs
• Consensus on drugs generally to be avoided in
the elderly due to potential harms regardless of
underlying health condition, age or gender
• Zahn (33 drugs/classes) criteria (2001):
– Never appropriate
– Rarely appropriate
– Sometimes indicated
• Beers (48 drugs/classes) updated criteria (2003):
– High severity
– Low severity
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Gender - Study Population
• Over 824,000 Medicare enrollees in 2002
and over 803,000 in 2003
• Ages 65 and older
• 63% female
• 9 health plans across the United States
• Average number of enrollees per plan
from 7,500 to 187,000.
• Continuously enrolled during the year
• Pharmacy benefits
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Gender - Study Design
•
Retrospective pharmacy claims data analysis
•
Percentages of Medicare elderly 65+ enrolled
throughout the year with pharmacy benefits who
received:
1. at least one drug to be avoided in the elderly
2. at least two drugs from different therapeutic classes to be
avoided in the elderly
Rates calculated by plan, age, gender and
across the total study population.
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Principal Findings
• Nearly a million elderly enrollees received
more than 3 million prescriptions of drugs
potentially harmful in the elderly
• Average 3-6 prescriptions per member
• 20% of enrollees received at least 1 drug
never or rarely appropriate in the elderly
~165,000 enrollees received 500,000 prescriptions
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Gender-specific Findings
• Women are more likely than men to receive highrisk drugs (Zahn)
– At least 1 drug never or rarely appropriate (24%
vs. 16%):
• Never appropriate: (5.4% vs. 3.2%)
• Rarely appropriate: (18.8% vs. 12.5%)
– At least 2 different drugs never appropriate or
rarely appropriate (4% vs. 2%)
• Older enrollees (85 +) slightly less likely than 6574 to receive two or more drugs (2.8% vs 3.2%)
• Differences are statistically significant.
• Similar results and patterns were found in 2003 data.
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Drugs to be Avoided –
never or rarely appropriate
% Medicare enrollees prescribed drugs to be avoided
At least 1 drug to be avoided
Year
2002
2003
Min
%
Average
%
Max
%
Male
%
Female
%
*Dif %
13.2
12.3
20.5
20.1
29.9
29.2
15.7
15.1
24.2
23.8
+8.5
+8.7
Female %
- Male %
At least 2 drugs to be avoided
Year
2002
2003
Min
%
Average
%
Max
%
Male
%
Female
%
*Dif %
1.5
3.2
3.1
5.1
1.9
4.1
4.3
1.8
4
+2.2
+2.2
1.1
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Female %
- Male %
HEDIS Measure: Drugs to be Avoided
• NCQA expert panel added drugs from the updated
Beers list to final HEDIS measure
• Total 59 drugs in 18 therapeutic classes selected
• Includes drugs used mostly by women:
– Estrogen (note: data pre-WHI study)
– Anti-anxiety drugs
– Narcotic pain-relievers
HEDIS 2006 Measure Definition
• Percentages of Medicare enrollees 65+ with:
– at least one drug to be avoided in the elderly
– at least two different drugs to be avoided in the
elderly
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Harmful Prescriptions: Women vs. Men
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Estrogen (18% vs. 0.1%)
Anti-anxiety, sedative hypnotics and benzos (12.5% vs 6%)
Narcotic analgesics and propoxyphene (5.3% vs. 2.2%)
Skeletal muscle relaxants (2.9% vs. 1.4%)
Antihistamines (2.6% vs. 1.3%)
Nitrofurantoin (1.8% vs. 0.3%)
GI antispasmodic – dicylcomine, propantheline (0.8% vs. 0.2%)
Belladonna Alkaloids (0.65% vs. 0.23%)
Thyroid hormones (0.68% vs. 0.1%)
Vasodilators - dipyridamole (0.36% vs. 0.28%)
Barbiturates (0.22% vs. 0.15%)
Antiemitics (0.25% vs. 0.13%)
Oral hypoglycemics – chlorpropamide (0.07% vs. 0.07%)
–
Underlined are additional Beers drugs added to the measure
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Prescribing Rates in Women vs. Men
% of Medicare Enrollees prescribed at least 1 High-Risk Drug
80.0%
70.0%
Any Zhan/Beers
Drug
Never
60.0%
50.0%
Rarely
40.0%
Never + Rarely
30.0%
Sometimes
20.0%
Additional Beers
10.0%
0.0%
Female
Male
65-74 Years
Female
Male
75-84 Years
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Female
Male
85+ Years
Conclusions
• Elderly women in Medicare managed care more likely
than elderly men to receive drugs harmful to the
elderly
• Overall high rates of harmful prescribing are of
concern given the majority of Medicare enrollees are
women
• High-risk drugs may pose more harms in women due
to smaller body size and physiological differences
• Measures chronological age: proxy for frailty
• Need to understand if differential disease burden by
gender, patient or provider characteristics explain
gender differences in rates of harmful drugs
• Need to develop drug-risk classification systems to
determine if there are gender differences in exposure
to harms from drugs, i.e. impact of including estrogen
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Implications for Policy and Practice
• Gender-focused interventions are needed
to reduce harms from prescribing harmful
drugs and improve quality of medication
management
• Medicare policies (i.e. drug benefits and
formularies) need to account for gender
differences in exposure to drug harms by
Medicare beneficiaries
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References
1. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating
the Beers criteria for potentially inappropriate medication use in older adults.
Arch Intern Med. 2003; 163: 2716-2724.
2. Beers MH. Explicit criteria for determining potentially inappropriate medication
use by the elderly. Arch Intern Med 1997; 157: 1531-1536.
3. Zhan C, Sangl J, Bierman AS, Miller MR, Friedman B, Wickizer SW, Meyer GS.
2001. Potentially inappropriate medication use in the community-dwelling
elderly. JAMA 286(22): 2823-2868.
4. Women’s Health Initiative: Rossouw JE, et al; Risks and benefits of estrogen
plus progestin in healthy postmenopausal women: principal results From the
Women's Health Initiative randomized controlled trial. JAMA. 2002 Jul
17;288(3):321-33
5. Kaufman MB, Brodin KA, Sarafian A, Effect of Prescriber Education on the Use
of Medications Contraindicated in Older Adults in a Managed Medicare
Population. J Manag Care Pharm. 2005 April/May;11(3):211-219.
6. Steven R. Simon, MD, MPH, K. Arnold Chan, MD, ScD, Stephen B. Soumerai,
ScD, Anita K. Wagner, PharmD, DPH, Susan E. Andrade, ScD, Adrianne C.
Feldstein, MD, MS, Jennifer Elston Lafata, PhD, Robert L. Davis, MD, MPH,
Jerry H. Gurwitz, MD, Potentially Inappropriate Medication Use by Elderly
Persons in U.S. Health Maintenance Organizations, 2000-200, Journal of the
American Geriatrics Society, 2005, Volume 53, Issue 2, page 227-232
6. Ensrud KE et al, Central Nervous System – Active medications and risk for falls
in older women, JAGS 50:1629-1637, 2002
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Contact Information
Corresponding author:
Lok Wong, MHS
Senior Health Care Analyst
Quality Measurement
National Committee for Quality Assurance
2000 L Street, NW, Suite 500
Washington D.C. 20036
[email protected]
Tel: 202 – 955 – 1784
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